MICHIGAN - Dr. Debra Simms wishes her job did not exist. "If I had to find another job, that would be OK," said Simms, board-certified child abuse and neglect pediatrician at Spectrum Health in Grand Rapids. In her role as a child abuse and neglect pediatrician, Simms examines and interviews children who may have been sexually abused. The clinic at Spectrum is one of two such clinics in Michigan - the University of Michigan Medical Center is the other - and serves children from 63 counties who may have been sexually abused. In 2012, the clinic examined and interviewed 392 children on an outpatient basis. Among those children, are some from Mecosta and Osceola counties, where there have been several recent criminal sexual conduct cases involving minors. "For most children we see, the referral is coming either from Child Protective Services, law enforcement, sometimes from court system or medical providers," Simms said. However, the advanced medical examination performed at Spectrum or the University of Michigan's clinics is not done immediately following a report of abuse. Once law enforcement is contacted regarding a possible child sexual abuse incident, the child is taken to a local physician or hospital, depending on the severity of the case, said Andrea Nerbonne, director of Big Rapids Department of Public Safety. "Depending on the type of abuse or assault or type of injury, sometimes we take them right to the emergency room," Nerbonne said. "Sometimes it's the ER that calls us, tell us to come take a look." Child sexual abuse is, unfortunately, more common than many people think, said Mecosta County Prosecutor Peter Jaklevic. "It's important people understand that it is a problem and understand the dynamics of it so they can hopefully protect their own children as well as understand the signs that might be out there," Jaklevic said. "Criminal sexual conduct is one of the most underreported crimes that we run into." Most people will get a "gut feeling" when it comes to a situation where something might be wrong, and they should not hesitate to report those instances to the authorities, Simms noted. "I think a lot of people may have concerns (about a possible abuse victim)," she said. "A lot of times when we have kids who are severely injured or sexually abused, people say, 'I wondered about that,' or, 'I was concerned about that child,' but people are afraid to say something, because they, 'don't want to make trouble for the family.' "They are afraid innocent people will be accused or the children ripped out of their parents' homes, or other horror stories about foster care. For child victims, sometimes you're the only hope they have and you have to step up and make the call ... We hope people have confidence that we're doing our best to keep children in their homes with their parents." Nerbonne said that children are not removed from their home without just cause. "When we get a call of suspected child abuse, we work hand in hand with Child Protective Services to interview the victim and look for past problems," she said. "If we have to remove a child, the prosecutor is involved right away." Examining possible victims for signs of abuse Another misconception is about the examination of a possible child victim is that the medical professionals are looking for signs of abuse, Simms added. "Approximately 40 percent of the time we do not find abuse, and that's a wonderful statistic," she said. "A child may have a medical disorder to cause them to bruise, or an underlying disease or disorder and we now know and can make the family aware. Simms noted one case in particular, where a child came into the clinic with extensive bruising. After running the medical tests, they found that the child had previously had an infection that caused them to stop producing platelets. When Simms or another medical professional interviews a child, it is for three reasons: to evaluate any injuries; to determine if the child was at risk of receiving a sexually transmitted disease or infection and conduct testing if necessary; and to reassure the child and the child's family. "Children need to be reassured that their bodies are OK and that we can help them get past this," she said. After the interview, in which a range of information ranging from family life to physical and mental health history is taken, the interviewing and medical examiners meet so the doctors can go into the exam knowing what testing needs to be performed. Then, a head-to-toe physical evaluation is done where the doctor spends a "great deal of time taking pictures," Simms said. To assist in documenting the child's health without touching the child's genital area, Spectrum uses a $36,000 imaging device, called a colposcope, which allows the doctor to inspect sensitive parts of the body for small tears or scrapes without having to physically touch the child. One of the most difficult parts of the medical examination is making the child comfortable, both mentally and physically, she said. Some abuse victims physically shiver because they feel cold. To make the child comfortable, the clinic's two examination rooms have individual climate controls installed and children are able to select a blanket from among those made and donated by local volunteers. There are no needles or any other instruments which can cause physical pain or discomfort for children inside the clinic, Simms said, adding that clinic is located in a smaller, more intimate building than the DeVos Children's Hospital. "It's a very relaxed atmosphere," she said. After physical examination, Simms and the other Spectrum workers give the child time to express any concerns they might have before meeting with the parent or caregiver to make referrals if necessary. Knowing when to charge an alleged abuser Once the results of the interviews and medical examination are completed, they are turned over to local prosecutor's office for review. "There are four degrees of criminal sexual conduct (and) the first degree is the most serious" said Jaklevic. "The one you pick depends on the age of the victim, whether there's penetration, whether there's touching, things of that nature." Choosing which charges to file in sexual abuse cases can be very difficult, he added. "Getting beyond the charging decision ... there's the legal definition, and this is when, as a prosecutor, I say to myself, 'Can I prove this to a jury?'" Jaklevic said. "Many people don't appreciate how high and how hard that burden is to achieve." In Michigan, police, medical and other interviews are supposed to follow the Forensic Interviewing Protocol, which was created as a set of best practices guidelines used to interview possible abuse victims by asking open-ended questions and avoiding leading the child to say or act a certain way, he added. "Young children under the age of 12 or 11, can be suggestible," Jaklevic said. "In the vast majority of cases, there is very seldom physical evidence of physical abuse in males or females, so what you essentially run into is that the child's memory is the crime scene, and how you interviewed them makes all the difference in the world." By asking open-ended questions, he added, interviewers can make sure the child wasn't trying to say something else. "Some children don't think of things in the same way or use the same vocabulary we do," he continued. In cases where the alleged abuser has confessed to the crime, there are multiple victims or corroborating evidence to suggest that the victim's testimony is true, the prosecutor still has a tough decision to make; whether to take the case to trial or make an offer of a plea bargain. The vast majority of cases are settled out of court, Jaklevic said, and that's the ideal scenario because the child will not have to relive their abuse by sitting in the courtroom with their abuser and being cross-examined by a defense attorney. Most of the time, he added, they have a strong case against the perpetrator. In those cases, Jaklevic weighs the sentence a judge would likely give - perhaps 10 to 15 years - and offers a deal involving a sentence a few years shorter where the victim does not have to testify in court. Before a plea bargain can be approved, the prosecutor must consult with the victim, or, in the event the victim is underage, the victim's parents about the terms of the deal. No longer a victim, but a survivor Once the offender has been sentenced or the case tried in court, the victim begins the healing process. One of the places abused children are referred, either by medical professionals or the court system, is Eagle Village in Hersey. Eagle Village currently works with 57 children between the ages of 11 and 17 who have emotional and behavioral issues. "The majority of kids referred here have some type of abuse, physical, emotional or sexual, in their past," said Ame Edstrom, Eagle Village's residential director. Counselors and therapists at the facility use a strategy called structured sensory interventions for traumatized children adolescents and parents to help abuse victims regain control in their lives. The curriculum is a series of eight sessions where therapists work with the abused to help them learn how to overcome the mental side affects of abuse. "The gist of that curriculum is to help kids move from being a victim to a survivor," Edstrom said. "Two things happen through abuse: They lose a sense of safety and a sense of self control. Once you give them the skills to gain sense of safety and control back, they can move to being a survivor. Abuse no longer defines them, and they perceive abuse as event in the past, no longer who they are. "It's unbelievable the changes they start to make."